Oral-Motor Hypotonia and the Role of the Speech Pathologist
by Leah Jolly, BA, IBCLC, RLC
I never thought a speech pathologist would be in my circle of breastfeeding support, but just a few days after the birth of my first son, we were referred to one. At our first appointment with the speech pathologist, Ellen Carlin, we discovered through thorough hands-on testing that our son had oral motor hypotonia, a condition of weakened muscles of the mouth. We were quite surprised when our second son was born a few years later and had the same latch difficulties, so we headed back to Ellen Carlin and received the same diagnosis. Both boys had weekly therapy with Ms. Carlin and a home therapy program we learned at our visits. When I tell other Leaders and breastfeeding professionals about our experiences with speech pathology and breastfeeding there is always a list of questions. The following questions and answers are from an interview with Ellen Carlin and will be helpful to others in understanding how speech pathologists play a role in breastfeeding help and support. Ellen Carlin is a speech pathologist practicing in The Woodlands, a suburb north of Houston.
What training/background does a speech pathologist need to work with breastfeeding babies?
A speech pathologist must have an interest in working with infants and obtaining additional trainings in oral motor function and intervention techniques. The speech pathologist should be a master’s level therapist, ASHA Certified and have a Certificate of Clinical Competency. Oral motor training is the key and the Beckman Techniques for evaluation and exercises, as well as Susan Evans Morris feeding training are very comprehensive trainings for oral motor evaluations of infants. Speech pathologists working with breastfeeding babies should have hands-on experience in these evaluation and therapy techniques. Additional training in sensory systems and head/neck and trunk support as well as knowledge of a variety of oral motor techniques and theories are also recommended.
What types of conditions do you most often diagnose and treat for breastfeeding babies?
Most often babies are referred by doctors or lactation consultants when positioning attempts have been unsuccessful, the infant presents with an unsuccessful latch, for suck/swallow coordination issues, leaking of milk during feeding, and general feeding difficulties that are not responding to normal courses of treatment/support. Upon evaluation infants may be diagnosed with oral motor hypotonia, coordination disorders and/or feeding difficulties and mismanagement.
What types of therapies/treatment are available with speech pathologists?
Treatment for infants who have been found to have feeding difficulties begins with a thorough hands-on evaluation. By testing range of motion and reflexes of the mouth, tongue, cheeks, palate and jaw, the speech pathologist can determine what exercises are needed to improve strength and range of motion for appropriate function of the muscles. The parents are trained to use their infant’s individual exercise program and encouraged to use the exercises on a daily basis.
In your practice, how does breastfeeding impact the outcome of oral motor conditions?
Once the infant is able to efficiently breastfeed, the oral exercise program may be weaned. Normal use and function of the oral muscles needed for breastfeeding, will keep the muscles toned in a typical developing infant. What I find in my practice is that once the infant’s oral motor strength improves and normal function is regained, feeding skills and speech/language skills will also develop normally. Keep in mind that children with other neurological difficulties may need additional support throughout development.
What is an oral motor evaluation?
The oral motor evaluation consists of two evaluation sessions. During the first session medical history is obtained and the mother discusses problems the baby is having. This is important because difficulties may not be occurring at every feeding and the mother can describe sensations or pain she is having during the feedings. A thorough history is taken to evaluate if birth traumas or other complications of pregnancy or birth may have contributed to the feeding difficulties. Next, the oral reflexes are evaluated to determine where muscle weaknesses exist and a feeding observation of the infant is obtained. The speech pathologist looks at the latch, jaw motions, tongue placement, lip seal, suck/swallow/breathe pattern and overall feeding behavior.
The reflexes are tested by stimulating different regions of the mouth with the finger while looking for tongue movement reflexes, suck reflexes, suck/swallow/breath patterns and jaw motion reflexes. This helps determine where weakness/dysfunction are occurring and which exercise will be helpful. The areas of oral strength ranging between 79% and 0% are identified, and an exercise program is initiated. Parents are trained to use the exercises and are instructed to use the exercise program daily. The second evaluation session is scheduled following a week of exercise use. The infant’s oral strength is reassessed and parent information is collected regarding feeding progress to determine if additional exercises are needed. Typically the exercise program is a ten week program.
What “red flags’ would a Lactation Consultant or doctor be looking for when referring an infant to speech pathologist?
- Absence of a gag reflex – infants should have a strong gag reflex, which is protective in nature.
- Reflux diagnosed – may signal difficulty with suck/swallow/breath triad. (The infant is getting too much air in tummy during feedings.)
- Multiple apnea and /or bradycardia episodes
- Difficulty with grasping the nipple after 35 wks GA – they don’t have the strength to produce a good latch on.
- Length of time to feed (2 oz. in 20 min is too long)
- Absence of 1:1:1 ratio for suck/swallow/breath denotes disorganization of oral musculature.
- Infants with a poor lip-seal, leakage of milk around lips (bib soakers) or milk coming out of nose.
- Snack and snoozers – mom’s report that the infant is always eating because he can’t stay awake to finish a feeding. (Infant doesn’t have the muscle strength to finish a feeding then wakes up hungry – falls asleep- wakes up hungry….)
- Infants who are loud feeders – they display inconsistent tongue suction during feedings
- Infants who clamp down on the nipple causing nipple pain, trying to stop the milk flow due to difficulty managing it.
- Infants who refuse the breast and will only drink from a bottle-may start and stop crying at the breast.
- Infants that require maximum flow nipples or cross cut nipples
- Poor non-nutritive sucking patterns
- Infants for which positioning techniques do not help with feedings.